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040-1097-60-200
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CROIX COUNTY, WISCONSIN SUBDIVISION LO'T LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM .,a INDICATE NORTH ARROW Top or S.0 lafi �c�K'aE� BENCHKARK: Describe the vertical reference point used T(E� - -PtA&Le- Blevation of vertical reference point: /0 0, 0 ' TOP OF (30s 7— Proposed slope at site: -/o Z L120 SEPTIC TANK:TANK: Manufacturer: Liquid Capacity: /Q 0 Number of rings used: Tank manhu'Le cover elevation: C, 1067- Zs' Tank Inlet Elevation: Tank Outlet Elevation: f(o ' 7� Number of feet from neare::L Road: Front,(D Side,O Rear, O 2 S feet D4 v From nearest pa c �%cr:t.y CP;c Side,Q Rear, feet I'S 04.) V Ei 6-N/DP s S'!--,-7 T- Number of feet frcn ��_____ ► . 41 , A _ Q��1 �'1 /O FT. PUMP R Man acturer: Liquid Capacity: ' Pump Mo Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,Q Ft.-. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: s Length: � d Number of Lines: Z Area Built:_! Fill depth to top of pipe: ya- " . Number of feet from nearest property line: Front, O Side, O Rear,O pt . Q , Number of feet from well: d067 zoo • Number of feet from building: (Include distances on plot plan). SEEP A IT Size. Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil abso tion sytems? (Check one). HOLDIN K Manu acturer: Capacity: Number f rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: / Inspector: Dated: • Plumber on job: License Number: F CkIESITE SEPTIC PLiid;,+c�::G 665 G'NEIL RD.,HUDSON,WIS.54016 3/84:mj ROBERT ULBRIGHT .VIS.MASTER PLUMBER LIC.NO.3307 M.P R.:: V IN,1:IVALLAR&DESIGNER LIC NO N)Pr` DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION MADI§ON, P.A. CON BUREAU OF PLUMBING W WI 53707 S1 4NE4, Sec. 29 T28-R19W ❑CONVENTIONAL El ALTERNATIVE IState Plan 1,13.Number: Town of Troy El Holding Tank ❑In-Ground Pressure ❑Mound 111 7gmld) HWY. 35 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Jackelen Bros . Auto I -(4-y I V,16o BENCH MARK(Permanent reference posnO DESCRIBE IF DIFFERENT FROM PLAN. EF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber. MP/MPRSW No County Samtary Permit Number: Robert Ulbrich SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCK)NG COVER PROVIDED: PROVIDED DYES ONO DYES ON BEDDING: VENT CIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. VENT TO FRESH ALARM FEET FROM LINE: AIR INLET. ❑YES E NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO 10 YES ONO I DYES ❑NO GALLONS PER CYCLE: PUMP ANO CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH 1111AMIT111 MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,constriction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH ', WIDTH LENGTH NO UISTR PIPE SPACING COVER JINSIDE CIA SPITS LIQUID TRENCHES. MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH IDtISTR PIP . ERIAL. NO DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER FEV INLFI ELEV.END PIPES FEET FROM LINE AIR INLET. NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS IOBSERVATION WELLS DYES ENO EYES ❑NO DEPTH OVER TRENCH;BED DEPTH OVER TRFNCH;ftEU DEPTH OF TOPSOIL SODDED SEEDED 7YES —CHED CENTER EDGES DYES ENO DYES ENO NO PRESSURIZED DISTRIBUTION SYSTEM: ,<BED/TRENCH' WI TRENCHES OTH LENGTH NO.OF L.ATERAL SPACING: GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER " DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE �MANIFOLDMAIERIAL. INODISTR UISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV. DIA. ELEV. PIPES OIA ELEVATION AN DISTRIBUTION tare I : HOLE SIZE HOLE SPACING DRILLED CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES NO ❑YES ONO COMMENTS: PERMANENT MARKERS: JOBSIERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE O ❑YES El NO OYES ONO NEAREST 1J, 3� I � Sketch System on 5 Retain in county file for audit. Reverse Side. SIGNATURE: TITLE DILHR SBD 6710(R..0I/82) DILHR SANITARY PERMIT APPLICATION EZ In accord with ILHR 83.05,Wis.Adm.Code CouNTy� # -Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERMIT ❑ 4?-7 8%x 11 inches in size. C oki v ision to previous application -See reverse side for instructions for completing this application. STATE P N I.D.NUMBER I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION J �1� jtL-e- - S&I Y. Pey, S ZS TZ N, R �� E(or)W PROPERTY 0 ER'S MAILING ADDRESS LOT# BLOCK � 5 / i7w 1 . 35 TY A ZIP CODE PH NE NUMBER SUBDIVISION,NAME OR CSM NUMBER yo i5 y/S II. TYPE F BUILDING: (Check one) ❑State Owned VILL GE '�'�(� NEAREST ROAD Public 1:11 or 2 Fam. Dwelling-##of bedrooms— P A OoEwL TAX NUMB E R( ) III. BUILDING USE: (If building type is public,check all that apply) _ j 3 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car ash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 K Other: Specify AVIiI0 IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2.�R Replacement 3. ❑Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit## _ Date Issued V. TYPE OF SYSTEM: (Check only one 2- 4 1A1,e 5 S )K&,&) r e-f Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2,ABSORP.AREA 3,ABSOR D AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE �� REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) Cj r �ELLEVAATION IAI? &00 • 2,- / 0- � Feet �T. a Feet VII. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks I Tanks structed Septic Tank or Holdina Tank Q e) Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: loo w T' 4us ilti% 3330 a Plumber's Address(Street,City State,Zip Code): V r IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial /�� O6' Surcharge Fee) Adverse D t rmination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ,SBD-6398(formerly Pib-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber INSTRUCTIONS . 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 605-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete#of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) ail sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of-standards. SBD-6398(R.11/88) VEt%. REF. PT. - To/' Or R-R• ?it- t CORNE'K Fc-cr- POST EIEu,= eoo.o' ?op of? per-V 6/--- - 10__ T•9-ENC4L SPecs - -su+- - - - - -- - -- 1- n�`Z o S'x 66 8' • I1 6F wAsf(�V 3/4 /ISsl2r6 rrE 'L Borl. ?(SeD U�DF1Q 2 S 72.1 "bit, r c Y" v� / I S`�rGO TRE.�,cQ►S 7YPfiR sy"Affic -1-A&Ric �6v�R-iaG- 0192 �p� - (jbx, • Uil� DQop- Z)'STP 601+0.,, r' IM - wFsT TQfNd. R5 -rop of fcfvs Is T- i¢a /" = 30 ,A 0 L, a v 31 3y�i v `J'•J. � o� G� SEyrre T. - Q 14,5f JACkE(�,; Av'b w/ f.4� (hs5 P.4 QA-r-;� fe��o �d�y w•TAcT ol X0 5 f !o° 13eNv y" fRast p�cn� �/D SEPTIC PLUMBING CO. N,OMESITE SE N WIS.54016 855 O'NEIL RD.,HUDSO ROBEIIT ULBR*VfT M P R S. �g MASTER PLUMBER I NO• ,JINN.111STALLER 6 DESIGNER y' 6 t ( — 145 - Buy - — PLOT P �-Ati t V w — BYO-nve7x 4F,,0v,Ja0n s �✓oj i % 9-�4 14 1 o�a/al7d f 1 CV) — I I I I I I I i I I I ku e3o i, I, ONSITE SEWAGE SYSTEM � I I (,onlAgnalfit t D[7P ARTo.,lE NT 07 yNt l-IR AND HUMAN RELATIONS ry Z 0 • Q- ,� T yr u ol � v -A `mow to 1-a.P X89 - 4038 ' a T R£,Jet.— / - Fresh Air Inlets And Observation Pipe Approved Vent Cop Minimum 12"Above Final Grade J5! 00 Q Above Pipe 4" Cast Iron Vent Pipe' 'To Final Grade .r Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 , 12 r Aggregate Beneath Pipe ° Pertbrofed Pipe Below 3/q 'Rom s-,1-- 0 Coupling Terminating At Bottom Of System S YSTFh 1ev,+ how 00 i' ..Z of 3 . 5 SO ' L. A13SORPT'100 CROSS SG-cT,OAJ TReiv a&- „ Q Fresh Air Inlets And Observation Pipe t • t Approved Vent Cop l Minimum 12" Above Final Grade 0,,A °r 1/,?," Above Pipe 8891 IEW'AGE SYSTEM "to Final Grade Vent Pip Synthetic Covering .M Min. 2" Aggregate -PAF T MoDil;+ C? t,,,, ,,r. Li;tiJ;3 AND HUMAN RELATIONS . Over Pipe U!V!�0 v O SA ,`]`( AND GS Distribution su. Z�,.y Pipe 0 0 0 0 0 s « r 12- " Aggregate Beneath Pipe ° Perforated Pips Below 31 " Toc.k s;.2a- 0 Coupling Terminating At Bottom Of System s ysrt)� lEV�t i Imp 0 X89 - 4038; '7 feuGEL/�f /S V7'Sr pw,,p"ry L:d� i., Veer&f.pr. M. SY PI—C)T L ----'$�--- s_ �-- , of cysreN � l� - - - - -- -- --- o pEu. 3z 30 13 1 • - �?C,Fh�p� f30,Qi.c��s W , � hE(2C IOC�tT�oas J / ���, 99.5' ,EDGE cr /A 1!1! = UE,p7. ktj A9 41T o f c T°/° of oefi/w4y kpoo0 k a Ltv L TiF. �UrPNE,(� FF-+CE o I `��. P/tRIE'%cJ (rte 1� POST". Tajo of OtiS! SENAGE S ♦ 19.5 C/lA y. y E�IAMi� f� ' QrPARTM�NT 0 SI; DtiSt W--f . q N Boa E Co h pe i aT(1171 RR N��h� C osr Pxoor 1&4d 00 r W•cAST CON G�liE � ,"000 SAR. wiesGe co . `19.74 0 S-UPT tc TA Jk - w 1dl, fi$ee-s/�fss 8>vffceS i'U1-�tcT ok QJ 0 I ZfAI DES � w A,y�, 11 I CCA)STiQv TIV j h �a` NeW . I fRar Pew I i I ItAP1710n1 S0 o�o SePTIG T4,N(L M 1,I ; i Z \I&R1Ff Tk*r IT 15 5rq t, GoDE GOM �r;NT.i 2 i I 'O 3 z i & -T � I ' M J k N fw� se e u To PA i,,)T �j�&. His coof , booR (6Aip .i'p\aT IIJTE'R10R A 4i ` C�2FASE-Dil 0 u� COMHO� � I Wei/ f �- I -r PC,mac,.- I e Ai a � �IEVATi'p,J - DV�L$ I o�F Se-Pt<< TAOK N o _ 9 .770 ' �5 L i S h,�s c oDE 4�0 Al NOTE W i lrRf4S'� ��vf�c�/�Toi2 1 AS eDCSTRbyL-D i y ^. /00 - - B f�tC�tv�tTip,a �R /Jaw �OD��%o✓ i goo' -,I S 8 97 40 3 8 . ; F�,�v, i ''/•�o,� sT>9T� ffwy. 3 5 ,P/� �j I o f toAV �- iOA-) tVL — CD^ �1E1QC(hL-- - � E-pt,AC� mIF)-j .�_SJ I .L .H.R. 83.08(2 ) PROJECT INDEX SHEET - s���E��� 3eos. Auto 3of)y <9 , Owner: ��Da UkC-10E1>=A.5) '71 S - 4zS Address : ttwY. 3S, �iueP, Fill.$, LO IS . 5*1o2Z,• Site Location : Sw �y /UC yy � S ec I ,Z S, T�Aj RI q W TOW,) OF T 20 y Tt' C ROt X c6vA.) ry . Project Description : �i ;k , C0PJvE'0+ 0AJ* . (COHMEjeCeAL— SE-P+t-c IA.! S"WhA i7o cv4S 'Pb�ce!o oN 40AAT` I'S Now ' taik Aixt'Ski�)dR's PPapC-Rry ( fJ A P M Cp. zt w*S 'DlS VEQEO ESTAgoYEL7 ('F4- '4-;,PAi'0 - FI1=l-0 SCC+ oa> OA.) V - 1y- IJP9 73% w0Rki4G- oN RN ADDi-Fio>J sys-fEM �7Xe-4-0cl�,Sl p R.opos a i,v s vi-t413/E Soils, (e-1,fSs T.) �4 r S. C'�. 'co�P�v�o r a.J fl e_ .vE; �s v� 's PIP p Eye T/ s� S Sizi � �. -rQE�,a,,., Hoop- P2�t a flow 2 2 0 u1R yp sQ• ��. . y pP-oposvo : goo Page 1 . PLOT PLAN VIEWS Page 2. M CROSS SECTION Page 3 . SYS-rEA-r I?�,��viECUs PLUMBER : HOMESITE SEPTIC PLUMBING CO. HOMESITE SEPTIC PLUMBING CO. 665 O'NEIL RD.,HUDSON,WIS.54016 655 O'NEIL RD.,HUDSON,Wig,solo ROBERT ULBRIGHT ' ROBERT UL~C577-#2 yp WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. W'S'kASTER PLUMBER LIC.NO.33V ALP.Ra Z MINN.INSTALLER&DESIGNER LIC.NO.00663 MINN.INSTALLER&DESIGNER LIC.NQ OM DATE : SITE EVALUATER/ DESIGNER �I SIGNATURE I� OCT . 1989 I' orV. S � 9 `- 4038 � DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, LABOR' DIVISION AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON,WI 53707 (ILHR 83.09(1) &Chapter 145) LOCATION- _n"'w o TTQ , OT HIP/MUNICIPALITY-__ . O. ISION NAME:�6 N/R'9 E( )w D� S � T-) !/4 Z COUNTY: O S ME: M N A S C,QoiX TgckE'GE u ,Pof. �. � o �s� y 35, ,P I;P6;p ffif 4&/f, - USE VOAJ JI dfir,Ut'7� / - LS- Z DATES OBSERVATIONS MADE NO. O S R TION: ❑ R TI TION TES Residence Avfc hjtit-i- ❑New ,Replace ��Ztl-- I CP eAPLOyEES Wi V, j e,4 re&-7-Arue4, d!;6 1Ao1 ,� ! RATING:S-Site suitable for system U-Site unsuitable for system ONVE ' MOUND: iN STEM LDING TANK:RECOMMENDED SYSTEM:(optional) DS ❑U S DU c❑S ©U ❑S ❑U 4 A00 eN41'0 ah 4. G7)< W S Gur d A-Iis7VIIRR ,a If Percolation Tests are NOT required DESIGN RATE: If an under s.ILHR 83.09(5)(b),indicate: C L�fS �- Y Portion of the tested area is in the Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS SN Tte.j, Aa- +err- BORING NUMBER TOTAL DEPTH T GROUND WATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, NUMBER DEPTH Flf ELEVATION OBSERV D S HES TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.jEXTURE,AND DEPTH i B- / e� s ` f7•o i /�2S ' 8/,f' Si/ T.S Si/ /,O ay, cou lt c E S/� 2 ' , C s/ CIF I/ s 3NB- 2 �rS, . l ?/k.S7/ B-3 9 0' 9y�y alp 7:S, 4,j Si. /.o ' dor S G, o r4,✓ c i i B- i . PERCOLATION TESTS iN . covTS'E S,4 V.0 $'fps-yS s DEPTH WATER IN HOLE TEST TIME j NUMBER ROOM" AFTERSWELLING INTERVAL-MIN. p R r)t DROP I p RI p WATER LEVEL-INCHES RATE MINUTES F-� � � Z y / / / PER INCH P- Z- P P- p_ PLOT PLAN: Show locations-of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9d"d a -- o fAr- I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): HOMESITE SEPTIC PLUMBING CO. lTESTS WERE-CO—MP- - oN: ADDRESS: 855 O'NEIL RD.,HUDSON,WIS.540113 ROB CERTIFICATION NUMBER: I PHONE NUM71�(optional): i WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. 2 Z-- 36 S i CST SIGNATUR DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.10/83) -OVER - r ptepQ►ry ��E l 3s ' S I 5' � � PL-or P L 30 3y l�o S' DOGE e r X = PERG IOCA-r#oa,s = G"7. erF PoivT iS rdp of ^Iwy woo TiE. eU,pe� � Posi rp l �9 5 y Sfo,er�,e- pvs r r /00, D tk 1 � [�f+1H►��D 3 R <oa - co•„p�P��T +��k &�f►'fri�Ct � I � � �Re•MSr eolp le �9•�p /pp0 d�• W fES� Cp • ( � � Se fre- TA Jk - w ► fi►stp-SI�ISs $i ces rNT.4 tr. i COAST PvbTioAP,, �Icw J 'O -321 kEcEN UTo PA w A. P.M, 131G� SERy,�E Af aHpcoy�Es �IEV�kT�O,J oV`Iar T.,A3v, T&.-7o ' MOTE .IM C�,S �fw• �DDi�`ro�l � � , STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �//►�K `�� ✓��-� / �"W� `� ROUTE/BOX NUMBER— /,57 / 3 FIRE NO. Is ( CITY/STATE ZIP s ` d Z Z PROPERTY LOCATION: 510 1/4 /U� 1/4, Section 2-5 , T__�_LN, R—LI—W, Town of I F-v , St. Croix County, Subdivision , Lot No.-- Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resour es. Certification form must be completed and returned to the St.Croix Count ning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address Y ' APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------------------- Owner of property Location of property s_W _1/4 N 1/41 Section 2-5- , T Township — T 90 y Mailing address �� ffZc� �- 3 S 40 2-2 Address of site Subdivision name Lot number Previous owner of property IYT Total size of parcel _ )- + A eAt Data parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes n No Volume 7 S and Page Number Z_ as recorded with the Register of Deeds. --------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described In this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. y Z S/,geO ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the Coun a of Deeds, as Document No. ) . Signatu E ner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature STATE BAs OF ws8WMW .�_ Tos1[f V ,t .. ,�TIM i. !f Sank o f Rive r Falls a ! 4W A iliw p r...... . te i calPo •. ..... ration, Grantor - ..._..... .. ..... . of t 9t a . ................... .......... i 8:30 s s; .-: ......................................... _ - �po'sai wsssads b ...JACk�Isn--grotbers_Auto, Inc.,. ...-- . . . ... ........................... .. ........ ....GTAR ee.. ..._.... . f 0 ... ...... ..................................... ......... ....... ,N ... .. ............ .. t R[7U1•I TO '-f,• + •......................... ". - .. _.. .". ................................_ (� Dow 4" ofi St• CroiX 111111111iil" Irem Ill to is ................... ....... .. County, _ MMM BALK (Sh) OF THE NORTHEAST QUARTER (NEA) OF SECTION &Vjozf *'• '1MIT EIGHT (28) NORTH, RANGE NINETEEN (19) WEST, YORE pMLfj F- 40iiaomtwg at the Northwest corner of said Section 25; thence go Est the >orth line of said Section 25 a distance of 1086.5 foot C Stafe"tlltnk Hi ghway "35";,, thence S52 e 35 49 E along the cemt*rib df`Mtsf ton thereof a distance of 2175.8 feet to the North • � !""eaid Sec, 25, thence N8S 33 E along said North line of the m filet; thence S29055'E a distance of 488.1 feet; thiemce .N teat; thence S32.191E a distance of 400.00 feet to the P9# ' bl► ' . ,' tarsal to be herein conveyed; *i>3t7,8 feet; L. I!" �4. ► `feet; feet to the Northerly right of way of ,State Trusk amid right of way 100.0 feet; 117 oo feet; p10.0 feet to the Point of beginning. a 1A Vi b6mmukad peopertr. ; easewente, restrictions and ri is-of " k 8h "may o�,;;#�, .. .-..- ............. • F . IRST I �v } (SEAL) _ ... ................... . Paul E. _webjch_ ViGq . Schwab .:.,.�. ►». .; - •• ..........--- (SEAL) µ i, :. Dellene R• „ �, 4 �{ Q. > f ,Allow { �� � xoti�ra�r - f� ................ sTATS or - s^< -- ................... Pierce d * r. �� l Apr .__• . 1s..8Z Pre: i!>r .. I. .�'rie�o tidy aM •� �� 'I, � ' ,�. .................. •� Sc� `•-ac�1 and. niceresi�eiif t ! MIN :Natioiiay ' to wo to io aft* : ......... . Pamela De_alY y Nota ag . dap t ;!MM+ ` be V0.4 ai.E..tNW Leo r °•-Itr oyv — /(9 J-7 — / 9,P� i -4-12 K -/ State of Wisconsin ` Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL SAFETY&BUILDINGS DIVISION Office of Division Codes and Application 201 East Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 ROBERT ULBRICHT Owner: DON JACKELEV 655 O'NEIL ROAD 151 HIGHWAY 35 HUDSON, WI 54016 RIVER FALLS, WI 54022 RE: Plan Number: S89-40387 Date Approved: October 2, 1989 Gallons Per Day: 220 Date Received: October 2, 1989 Project Name: JACKELEV BROTHERS ALTO BODY CO Location: SW,NE,25,28,19W Town of TROY County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved' . This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - REPLACEMENT CONVENTIONAL Inquiries concerning this approval may be made by calling (608) 266-6952. Sincerely, `W C�K GERARD M. SWIM Section of Private Sewage Division of Safety and Buildings cc: DON JACKELEN X Private Sewage Consultant SBD-6423 (R.08/88) ` REGISTER'S OFFICE 45xt��; • � �:�.�PACE�� ST. CROIX CO., WI Recd for Record cat S EP 2 7 1989 3:50 p M EASEMENT AGREEMENT Register of Deeds This agreement made thisep day of September, 1989, by and between Dale S. Durand (hereinafter DURAND), and Jackelen Brothers Auto, Inc. (hereinafter JACKELEN). DURAND is the owner of certain property described in the -deed recorded in the St. Croix Register of Deeds as the "Sheriff's Deed" to 1st National Bank of River Falls, WI dated March 10, 1987 in Volume 771 of Records on Pages 220 and 222 as Document No. 423166. JACKELEN is the owner of certain property described in the deed recorded in the St. Croix County Register of Deeds office in Volume 775 of Records on Page 275 as Document No. 424580. DURAND has agreed to grant an easement to JACKELEN across a portion of the DURAND property and this agreement is made to evidence the grant of that easement all on the terms and conditions set forth herein. . Therefore, in consideration of the mutual covenants contained herein, the parties agree as follows: 1. DURAND grants to JACKELEN an easement to install and maintain a commercial septic system on and under the property described in Schedule "A" attached hereto, which easement is subject to the conditions set forth in Paragraph 3 of this agreement. i 2. In connection with said easement and sanitary commercial septic system JACKELEN agrees as follows: A. To pay for the installation of the septic system according, to present required standards of the State of Wisconsin. B. To maintain the septic system in good working order at their expense so as to cause the least interference with the remainder of the DURAND property. C. After the installation of 'the septic system to bring the property to the same approximate grade and gravel or blacktop the same to match immediate surrounding area.. yr� 4 � ti 44 "EV 3. This easement is a perpetual easement, extending to future owners of the JACKELEN property. The parties agree, however, that the easement will terminate if the following condition arises: A. As such time as the JACKELEN property is served by a public sewer system and JACKELEN is afforded a reasonable opportunity to connect to such system. 4. This agreement shall be governed by, construed and enforced according to the laws of the State of Wisconsin. 5. This agreement shall constitute the entire agreement between the parties. Any modification of the agreement or additional obligation assumed by either party in connection with this agreement shall be binding only if evidenced by a writing signed by both of the parties. I 6. This agreement shall bind the parties hereto, their successors and i assigns and rights given to either party and the terms and conditions of this agreement shall bind and inure to the subsequent owners of the DURAND and { JACKELEN properties. R IN WITNESS WHEREOF the parties agree and have set their hand seals on this agreement the day nd j y year first above written. Dale d Jac e e rothers Auto,i-�n c Donald P. Jackelen, President State of Wisconsin County of St. Croix Signed or attested before me on September 20th, 1989 by Dale S. Durand and Donald P. Jackelen. NOTARY �y Michael A. Danielson My commission exspires 4-1-90 PV8L%Q �NgrF Of W1S������f 952PAGE2S, 0 PART OF THE SOUTH HALF (Sh) OF THE NORTHEAST QUARTER (NE 1/ ) OF i SECTION TWENTY FIVE (25) , TOWNSHIP TWENTY EIGHT (28) NORTH, RANGE NINETEEN (19) WEST, described as follows: Commencing at the Northwest corner of said Section 25; thence o C East (assumed bearing) along the North line of said Section 25 a dis- tance of 1086.5 feet to the centerline of State Trunk Highway "3511 ; thence S52°49 'E along the centerline of said highway and thereof a distance of 2175.8 feet to the North line of the Sh ofnthen NE 1/4 of said Section 25; thence N89°33 'E along said North line of the Sh of the NE 1/4 a distance of 387.4 feet; thence S29°551E a distance of 488.1 feet; thence S57041'W a distance of 56.2 feet; thence S32°19 ' • a distance of. 400.0 feet to the POINT OF BEGINNING of the parcel to be ' herein conveyed; thence continue S32019 'E a distance of 100. 00 feet; thence S57041'W a distance of 217.8 feet to the Northerly right-of-wa of State Trunk Highway "35"; thence N32°191 W along said Northerl y rig - of-way a distance of 100.00 feet; thence N57°41 'E a disance of 217.8ht feet to the Point of Beginning. Subject to easements and restrictions of record. I i i I I tz:E : -S ANITARY PERMIT APPLICATION HR ' In accord with II-HR 83.05,Wis.Adm.Code COUNTY j' lf ���V STATE SANITARY PERMIT# ! -Attach complete plans(to the county co ' ��t �,'� 8%x 11 inches in size. ❑ct,eck ittevii on fo or evious application -See reverse side for instructions for completing this application. STATE N I.D.NUMBER 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. 5 � PROPERTY OWNER PROPERTY LOCATION i1,4fQ.' It ti XA44 5 . &!t- i,'•0 % "+/,S V�, N. R I - E' or W l PROPERTY O NER'S MAILING ADDRESS T# 49C9 ITY,STAT / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER NEAREST ROAD U. TYPE] F BUILDING: (Check one) ❑State Owned VILL CITY AGE 7 k�fr? 3 ICJ Public Ell or 2 Fam. Dwelling- of bedrooms M III. BUILDING USE: (If building type is public,check all that apply) „ Z � 1 3s `T 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Vash 5 ❑ Hotel/Motel 9 El Office/Factory 13 ® Other: Specify 't''`� IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2.IQ Replacement 3. ❑Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B)�- ❑ A Sanitary Permit was previously issued. Permit# — Date Issued V. TYPE OF SYSTEM: (Check only one !15 c' .-- Non-Pressurized'Ustributit7n Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trgnch 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 4� ( Vjult Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6.SYSTEM ELEV. 7. FINAL GRADE REQUIRED(sq.it.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) r ELEV TION �v !'+ �Q.0 Feet Feet VII. TANK CAPACITY Site In g aiIons Total #of Prefab. Fibe Exper. INFORMATION New istin ,Gallons Tanks Manufacturer's Name Concrete Con- Steal , glass Plastic App i Tanks I Tanks I structed Se tic Tank or Holdi no Tank X !9(2 Lift Pump Tank/Siphon Chamber " ��.! . VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Phone Number: a�lit,P T ZfLt3 1;r46 AT �,�->� x'36 ? Plumber's Address(Street,City,State,Zip Code IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee(includes(groundwater Date Issued Issuing Agent Signature(No Stamps) Approved Owner Given Initial , - Surcharge Fee) ,�... dverse X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL: . 1 SBD-6399(formerly Plb47)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber y � k L D T "jD&;jAJ i i 1 F0 2 HELP 1 ti 48oLIc-- Jll-4j0 i n ,,fF- 7 y '�2 V WA of T t � G�c �i�A �FFI � i� Pos 1p p III g 133 13 OR ie 0 p I I i i i I HOMESITE SEPTIC PLUMBING CO. j 655 O'NEIL RD.,HUDSON,WIS.54016 ROBERT ULBRIGHT WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.& MINN.INSTALLER 5 DESIGNER LIC.NO.00663. f i ® � / 2 c % § . Q \ ; NMI : _®« ƒ eX-55 e© 0 { m.0 &C (U— Cc ƒ k]$2 (A (A [§a �5 ($a2} 2 / JE-- } ) ) 8 X2 > ° a 0 U)CD m 0 � $ ° a / z z �' k k § 2 a® m m 2 C- � $ e z k K ) / 7 7 \ z ` / / N e e \ 2 } t E \ z co z \ . z ] , E . ® ii L. 5 cc c CL ICN 2 k 'L ® - E ' k CL t a a a IL . a / \ § 1 — 0) 0) LO \ \ § \ \ . f m ' 3: 2 4 'o / ® _ 2 « 8 � 2I \ 9 I E « 77 / f c b £ 8 ° ` B @ 7 ^ G \ e § f / - k § } f k ) / � 2 � « k J k \ . § a E $ ) § 3 = & J a 2 2 Parcel #: 040-1097-60-000 08/19/2005 09:17 AM PAGE 1 OF 2 Alt.Parcel#: 25.28.19.386H 040-TOWN OF TROY Current X ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner DONALD P JACKELEN O-JACKELEN, DONALD P 151 HWY 35N RIVER FALLS WI 54022 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *153 HWY 35 SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.987 Plat: N/A-NOT AVAILABLE SEC 25 T28N R19W PT IS 1/2 NF 1/a C M NW Block/Condo Bldg: COR SEC 25 E ALG N LINE 1086.5'S 52 DEG E 2175.8'N 89 DEG E 387.4'S 29 DEG E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 488.1'S 57 DE E 400' 25-28N-19W POBS32 DEG E100'S57 DEG W217.8' TO NLY R/W HWY 35,N 32 DEG W 100'N 57 more Notes: Parcel History: Date Doc# Vol/Page Type 04/01/2003 715479 2190/543 EZ-U 10/23/1997 567311 1272/64 WD 191419 4 LC C1-078/556 WD more... 2005 SUMMARY Bill M Fair Market Value: Assess 0 Valuations: Last Changed: 11/06/2002 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 0.987 26,400 164,600 191,000 NO Totals for 2005: General Property 0.987 26,400 164,600 191,000 Woodland 0.000 0 0 Totals for 2004: General Property 0.987 26,400 164,600 191,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 040-1097-60-000 08/19/2005 09:17 AM PAGE 2OF2 Parcel History: cont. 995/241 QC 854/314 patLegal Description: cont. DEG E 217.8'-POB, EXC 386J INCLUDES P386J-10 SAM .1 REPORT �►Ix tcour, wisc NSIw, r i, +.�r*..+��.,.....t.. 1 irElri . Ax } 3 k i . I VIEW xements cad H-2.2C� fi yy t 5 sWITN �?F STEM. ' � t ,tech � h �, = S• S ' �.t t s➢,r�h t a., 3� , ra t, S ( F y a� l . � 4t iP Y• 1 M � � ��a � '�Si"'r�� ,� r tit � ,b s � �t �� ��. krd t •t �y'°H .,��� � a tl.�i x'Aq,�y� to it��'r��1t -, � Zn� ✓ 7 •� �`� ; � i i4�wz�vyr r .1.'.k , a yi IM I h , t t q '�y'Y4aRrvF � 3tt S �n 4f �( fbgY �jL q jd !t T t 1 ,.yy ih n Vcr f r ' A K.51810.4 ,,r� i 7-77 to, ct sy z SC=; ou�tt t c oa, s not imply ComPlete #'W' 4 trat:ive , 40i "there are' o.the�r ar a :that is not possible can t^ tct t 5� + �roix� county, assn sum" rice lability for �Gaoa}�� s + ec h Cy..Mill make every effort to ' F1Is �OT 004 $t dt PS�s G,�px a Nd7 � `al's: fly+ Sir AM, + '�Ayy yy�y . 4, t �R�7wM l y �. y firJ'���s Nt. r tf rf, ! { - .: n Z. - REPORT OF INSPECTIOIJ_INDIVIDUAL SEWAGE SYSTEM San.itaAy Petm.i-t State Sepxti = / V ;. NAME � -� �� Township ��. St. CAOix County Location� - S e e�io n 5' _ i SEPTIC TANK Size ow gattonz . Numbers o6 CompaA.tments I Distance FAom: Wett 6t. 12% on gnea.teA ztope Bu.itd.ing 6-t. Wettand6 it. H.ighwaxeh it. DISPOSAL SYSTEM Distance FAom: Wete gt. 120 oA gneateA stope it. Building it. wet.Cand.6 ""'� Ft. H.ighwateA_ S.t. FIELD DIMENSIONS: W id-th o4 t.te.n eh it. Depth o6 Ao ck b etow t.it e–ZI—.in.- • r Length o6 each tine it. Depth o6 Aock oveA t.ite 2. .in. Numbe&, a6 tines ,� Depth o5 tite betow gAade Z in. otia2 2eng h a nes j�_f 6t. Sto pe o6 xAeneh in pen 100 it. D.i.6 tanc,e between Zines–Arm—it. Depth to bedrock St. To.ta.L ab.6 o&b,tion anea 6t2 Depth to gAoundw ea 5t. 11 2 Type a r Aaw .. Requited aAea � yp � Cave Pape oA St p PIT DIMENSIONS: Numbers of pits GAavet around pits yea no Outside dia►nee Depth betaw in2e i . 2 Totat abzoAb on aA a it A AAea Aequ d � 2 i rn INSPECTED BV TITLE APPR(IV ED , DATE 197 . REJECTED ,DATE 197 / V - 3 b � S PLEI 670' State and County State Permit # // Permit Application County Permit # ' for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED f �/ Date Approval Received from State if Required / State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 6-74 K V 50 44 � B. LOCATION: %, Section TAIX N, R_ E (or) 0 Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township U w C. TYPE OF OCCUPANCY: *Commercial—_ *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY / 6r) Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete�_ Poured-in-Place Steel Fiberglass Other (specify) New Installation %e— Replacement Lift Pump Tank or Siphon Chamber _ Total gallons Prefab concrete Poured-in-Place Other(Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. New X Replacement Alternate (Specify) Seepage Trench: No of Lin a Ft. Width Depth Tile depth (top) No.of Trenches Seepage Bed: Length 7 0 Width 9 Depth Tile depth (top��No.of Lines IQ Seepage Pit: Inside di ;ter Liquid Depth No.of Seepage Pits Percent slope of land_ 76 Distance from critical slope WATER SUPPLY: Private ❑ Joint 1. Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME C.S.T. # 11537-1-11-9 and other information obtained from .J' !C C (owner/builder). /� Plumber's Signatur µp/MPRSW# 7947 Phone # 7/576er- 6y9 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. 3 E � e F t i -. 3 7 l g# Vtbp 7-, > t E E E € m. n �m t � Do Not Write in Space elow FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application Fees Paid: State 10,(0V Count C� Date -� Permit Issued/Rejected (date ��//�,� Issuing Agent Name _ Inspection Yes No State Valid# Date Recd 1. county (w to copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 L state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 ��. � "!•r a�,i � mew h ;.r R �� r t � r>, _,pt J 'n � f �.� } 1,,,�� �� �� �j��5t^�, ,ry✓ P. 'I a�' {�,'i ,.,4s 'S.'�c'� b7'3.' a�� r. 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''.E SY �i!? , u' a- Z.yyj, k RL"�; ',w3,r '� y��R y'„y. »�a r� �� f', + 4=•"° r �� � .r ¢';,'` t” ; *�K,it - "•�,� �,t.,t��r �'71 { 'tr] '� x *�} r rF .,vJ;r r+--;`� �i`� "� 'x`�•S � .�_� �,_ �'."'_t d 'r' '�y � ��� �� �;t A4 "N.,'`'3•,-:X��u fib, 'r .`. t%:.4 ��`°. n,:i, ,� 'le- 'A+ Vii. �, -`�, r r rt 4• '�` is � sue-,. a, w, ka }t�. .��,,•c st t` .�t 3".'x. t. a ,.',�1 r -�, °ie�."n° �+ q ":s„ r °fi'�M 1.1�T',�'$fy4 � _ 'rYx� 4�s,,f -}t n•' �t '�+. "�..'. y � � tt'�-„, 'fit t�. at - t �� ."'t Ni r,,yX k ti '� �f J� •�' � � �t t i' wwl� s v *' �''.� tr .ire�K :vs,•k �i` `'�`°Nd�t ��a -./}< ��v�t� `Y �E �: �!'�'•m}� A.� y�” � t �y'. �_.,,' s#°�,N h �:r ,• "t i.�, :`�� �..'�' T",�,?' 26$`'G�'�`�. .: ig.y..�,rr d t:.'�� r� <.� � ;;.4 -i#�.j' �, �lvrii�`e.. i,X'.>, 4'y av -.,�' i`�` � '+sic.�� ..'k'4 r`11' f r i,,�:� �• �y,�iy z:A �,�"�t � r ��, * 1{:-: , v'k"re is y 'i5. 7• "+�» J „� t'- vj" �, ,� .: $itY .,F.v:nL -�hti 14� .1�.��.' S.'r~,`, - 'tit •i � ,�; kj �} �.-.:, t'. it �r a e� ��°+J` 4, rR ��1��M.'�L r� • � � a`*. d w rt � r�� F�<'i,1sJ. ��"_may �lt�- �� a ,qty-,� �..•��•a,+ �M �w��� � �t � f i, Nil J �,�" � .'ya� "�'�^-Tom' ���+�,� "F' •'t� � x "i. r• i' a - � � i �. �, 4� �•,�;�� -3Ei`x,.":�R-k _- �y�'k �'� ��� Srp'�.M .t ��� Wik State of Wiseonsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH MAIL ADOR[ff: P. O. f0% 809 - MADISON. WIfCONfIN 68701 13, 197a IN REPLY PLEASE REFER TO: SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS yt hul Cudd A Sys « � Pt Identification No. Route 5, Box 364 y �` f' Many River Falls, WI 5402 �'✓ �'`����� Dear Sir: Re: GAW S Body Shop - Gary S MOW, aawr SeWage DispOsal SE 1/4, NE 1/4, Set. 260 T28#, R19W, Tom of Troy, w1 - St. Croix qtr This is to acknowledge receipt of your plans and specifications for the above- indicated project. When referring to this plan in the future, it will be absolutel necessary to utilize the plan identification number assigned to the project. The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section H 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the Department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates the plan review Fee required is Fee received is ❑ Plan accepted for review. Fee is being returned because of ❑ Overpayment ❑ Underpayment. Providing one of the two catagories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. ❑ No fee has been remitted. Plan submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. ❑ Additional information required. See attached Plb. 100. ❑ Affidavit sent. ❑ Plans being returned. See attached Plb. 100. Sincerely, a es A. Chief JAS:lds ` 1 X r. � xiys� �b _ d j ," i # Wt 4 tS1�1t pEl�!/ Ft'C�+If.*1r F,*4tALTH AND St IAt» t 1,F. �� :r ; ',',, ptivi44 6 1444 ,4 i6 3 o tit~ NVFRt NM i�1TAL MIrA t' w '-;'11 ' A �'.Q.:84X 309 a ' " ` IMAM N,WIS 1N tN 6 "Q� " i 'S v i k F k �f�[,' A +,11 V / ' AttL BtJ # S ENO Pt�CCkL�i' tttt t trSS: e f k.. 4 t - _ ` ; i k �C•X`I I T' r A+.I TI ►A b&I tC�? o dk I I"11 e P'v 4, "��I ia1p},�lF, .c..+..,....+" C:1I ., N1 4OU�� ,u„ yy �' k 'r'1. 4lort IrtB i S.I`"" A }} 3: .4' - 1 q t� /• _ 4 '' i d,l _ i area. '•' y t d ., � F :,, . i "• " +1P oC ,N 1, �Itge: I _., txf slroams- =Qtt►er r. I+ titrhSt: 1 tiff :: AD t`t IDN I'll_ R w_T_____ REPLACEMENT t 3ES,C3�fS RVATIUN Nt'#Qf S4f L B tfiNGS', 1� ,}sr .t'ERCQLATIpN TESTS e . 3l _#1�0.�` *kTT_ "° 501L"TYPE _ k' H "," N PEi3CQLATION TESTS ,1. ''' � Nau ss WATER IN T6S'f TIA+tt3 OP tN VMA R LEtiRE .",i r f>zftk IL SM tiflt 6 LE Ak�'FE INTERVAL �' „.r Mfi1I4} + 1ST ?C'r # "SIN -, +#G HV;MII�IU S PiiRIQI # trlit'111- s a ° ti n .. a .,+ k r, y ;i a K r Y "ACS i �"' f 11 s=° Y �} *`r x yetk '��' t, Jed''r y a: ' t 6a� + �I : r'' .e" `t •< " �. e" .�°`,'a ` ~:. a'4�'�"•`�,"�+h Ytw, .t�.".'�". ,�+,,r, '�' `". .,"ry�.�.} s. ' a s x+d� .r3 I .N '" ''"� 'tie .111,r; 'wf t" .w. ,�'.y.A r b c R+a a N _ .t z.1.J, t L t 1RiPit� i'9STS�, j ;'f� -�'4 dr,- t ' . l�t'TH TO PaRQUNiJWATEII,iIyCH,S CHARACTER OF$611,,WITtI THICKNESS, INCHE6 ' Y,i a INCHES ,' - bBSEcRVEQ` eSTIM'ATE Ht�HEST IDEPTM TO BEQROCK 1F OBSERVED) :r +� a S E " " w«r «w - w -�a... � - d "K « q 'AIM ,+wy,a «en+ .+r.+�� 1w�,ar.,..w.*,�«)5�d.,r+Y 4x'rrrrrrr iti Jf M Y r 5 4..' a i 2u YCry. 7 F '> ,t4 r xr ', k k ► N Vt�h �t a 10rcolat-ioi!# tl bore trrsles eiicl rota to soil areas.) I-i� � � t9 4It� 1nae. gtia�sr)d squrat feet of sutttMe areas. Ind#c ate number of square feet of absorption area 11 b 'R a f t tt I I L'aan. y+._ ��°„ r ,; »,—. -..__-__.._----- Indicate scale ' ' Titan ar'xA�atet andrticat ref" nc points.fir„ i ,h errs, is Indicate I slope. *, w- ",�, I 11 L.Xy r y 1. k ;*.: ... I It' �� 'Z n °ti _ a albs ':x�S a +, ,. cn r,'"r + y„ 8k : 1. , ! 1 Ir s n f 4 a. -=-„s 4 —#- - W -'t" 7- -rc 4 '�. .•N f! ,,,,,if {.. .. , .. r „ ,-», .-— + � MM _ -•-_ -._... Vii._."I I t � .. w I. I .I _ _ r.... 6 p 11�Ijj" s yy. !11 y ,�, � } _11.' .'w t~ C .w. Y ? F �, kt .r' r :�� la G _ s,. i - t 1y __ __ _ s I'll 4. � ���" PL 1M;R16 S fly i. . ' rCed on'thls fbrFt►vuere male b1r me in arrf with the procedures,11 5 . l �rst n fx _ t 1 t#y tt�alr# #I 1 st ,x � #rid �y� N isv d nts � xe CtI 9 a+ist tl t`the da#a recur , ,and location of_test#rotes are a rrea~t 5 � ,.to',Atli 4 ,r ,: � I ICt I7eIIeiL 11' y Cert�fiCattlDh No _ F r ,� ��1 ..'�, .CAB la�j r,ed" .,4 f Installer If It'no�+►n "�°"11 L � ,1 �, ., �' -�!I'�� ��L � r . I � I,I I ", . I r I ,1 4'..,I I CST Signature �_ �, '+-0 ,j, F �.y :! En�''t'-n6l'r.tal h3>r-'atjtjp, Div�P;,rc.ag ast I lr,,,as.te / O PROJECT.DETAIL DATA SHEET . '78053,1 NAME OF BUSINESS &Arely'S hoDy S Wyl> S-M— -rev" T LOCH io N 4a 1 ►,�� 3 S i..?0 2-T'► -r'�u� .�--['- C;r2.ta 1�- street or highway township county LEGAL DESCRIPTION Z Aua� k ,� s y or- � r zee r-+ O14NER AEt ,' So"W&CeVK Mailing address 530 14 CA-MC 1��Jkdl� �.au wiS ZIP Soz AACWTWOR ENGINEER S RAC S L. V-A oy-g++,r' Address 3 1 - t- 1 Z-KJ ST, gvLB� r ZIP 54-ozz. PLUMBER `1P IM Address Z4(,,o Lh-L-r S-c . e k J t� �ikl.t-�i�W►1;, 21 P 154-o z.7 . 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed, iz srx 1~X;sting W.1Iding New bui ldingr . X bob* sNuP Addition if addition to. ex sting building attach detailed memo for-each. ), Drive In, restaurant Car spaces ( staurant . ... .. .. ... ... .. . . Seating capacity (10 sq. ft./person) ( )` Dining ha'l I . .. .. . . .. . . . . .. . . Per mead served Toi let waste Yes ( ) Motel O Hotel O Cottages Number of units s: 2 persons/unit 4 persons/unit TOTAL NUMBER I #� k O Churches . . . . . . . . . .. . . . . . . . . . Number of persons Kitchen Yes A d ! O Bar or cocktail lounge . . .. . . Seating capacity (IO sq. ft./person) r, O Nursing ,or rest home . . . . .. . . Number of beds ,. ( ) Mobile home park .., . . . . . . ... Number of` un;its dependent camper tra3l+e nondependent (mobile h004 ( Retail Store . .... . .. Number of employees � oY :5 40P Number of customers ) ►z,f ,Y ( ) Service station . ... . . .. .. . . . Number of cars served (daily) O School . ,'.,, ,. .. . . . . ., ,, . .. Number of classrooms Meals served Yes No Showers provided Yes No i O factory or office building Number of persons (total all shi is O Apartments .. . . . .. . . . . .. .. .. . Number of bedrooms OOther . . . . . . .. ...... . . ... . . .:. Specify 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes No x Dishwasher Yes No m Automatic clothes washer: es No k Automatic potato peeler Yes Other . (Speci fy) _ ._ _r No _ }c 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned 1000 6w Pri-Lvi..i M9 Percolation test results —ATTACH PERCOLATION TEST AND SOIL BORINGS REPORT SHEE -.._ --- NOV 1 13M COMPLETE OTHER SIDE see p 4. age trench bottom area planned width linear feet depth SeeP896 bed area p l ann ed \'z x , -----'-�.. .._.. Twidth 1 inear feet c �. 4?depth r� Seepage Pit planned outside diameter depth below inlet depth 4. Sea approved plan for specifications and details. Signature of arson lc P anpletin9 form: STATE DIVISION OF HEALTH, PLUMBING SECTION :. P. 0. Box 309, Madison, Wisconsin 53701 Approved: Address t :�v Z'_° _...'_" ,� ADate: fill ZiP� C0�S��' jiS APPROVAL IS BASED ON STAT E PLUMBING Dat*.*r /o ' �/ '' REQUIREMENTS AND DOES NOT EXEMPT THE '� :�� JAMES L. 'WNIUNTY LLATION FROM CITY, VILLAGE, TOWNSH IP MURPHY REGULATIONS OR PERMIT REQUIRE ,. 2 7 9 MhTi AND SHALL BE VOID IF REVISED WITHOUT RIVER , Fa��s MR I TTEN APPROVAL OF THE DIVISION OF © ' � tL'tif ,r - wtsc. DEPARTMENTAL USE ONLY l4 Ok �!!!/lU If FN hhYFM1W4�w'� e by the tea° se�sNe°\�b o�ed ion Sy of •tees. . C.Ne O d e Q�P�4�� `S, Sep ��°n r So ter-. o� Pt�EQ°man a1 °� �'��e �e%a`��°�S �9\' 490� ok NP 5,� �no o{ eeti� to °. 0, e4a�NXV1 C' ,ESA of Q -.4\. y, s4 40\• 6\ the ce���'GQ OP4,0 oJ�O bSo6\c � l °{ ee QQR Ora the P \-k O �� `r ��•. t0 SO GOM00 �e�.F Seepage, trench bottom area Planned width i. linear feet depth Sealaage bed area planned 1 Z width ,� "'�""--------_ 1 � P,' s'• 12` linear feet k '• epth Seepage Pit planned outside diameter depth below inlet depth 4• See approved plan for specifications and details. Signature of person completing form: ` STATE DIVISION OF HEALTH PLUMBING SECTION P. 0. Box 309, Madison, Wisconsin 53701 Approved: Address s s ,/ 1,'n ----_' - jY Date: 4 l �tttttn�m�iunnii�ti� u ez 46S t�s Z I P �t, a 4 c•,,. O •�,.. ........ ,Sj ' #i S-APPROVAL I S BASED ON STATE PLUMAI NG Date• /a -��- .• • +••° REQUIREMENTS AND DOES NOT EXEMPT THE � �: JAMS L, f_NSSALLAT I ON FROM CITY, VILLAGE, 701�iNSH!P MURPHY C UNTY REGULATIONS OR PERMIT REQUIRE cc��M,,__NTa AND 7 9 SHALL, BE VOID IF REVISED WITMOUT 'Tfi1$' R I TTEN RIVE( BALI S, R APPROVAL OF THE DIViSit>i�t OF WISC. DEPARTMENTAL USE ONLY : }I«.FFfi1kN 04 SeXV°n 'the �tep,� b`l 6 °S`15te�st��ea�th, . \00 a •c aka I 6pQ le�V' 0\ a\5ew` �S• 1N�� Ftce ea�t� d c .._ ,e to E 0tO 6 01 °04 L F�<e Pc° pept:�'t oas �a�t<Q �t of SAS j\o4 Nea`t�o cA� °pePat� FPM S�0 v�sto� °��ve``• Se t'° the Vet'4 Gc 11 Ov�� bs°c`�,t Ket °4 dQp yet �o ve<`f`Gdtor j 71 + '^ ua i o Vz QA C- s O_ coo p �a W A r o a c d ti ° o X r mc LL xa °au�i o ° hvtF- � Q I aC_ O >.� 3� I �.` m N mY 0.0 0)=a O.N •O. C m— m 0 0 CL _Ile VOl a 0 0-0 V O a) c O) C a) a 0 0 0 O ..L•j 1� d New �. U 7 p- y.>>� a)._w 7- z° �U> v Z v m CLCL r'g a E= c rnm c y ° LL c o o € ti c �'R ° 3 _� m0 C. ° c° c o 0 0 m �c a a ° La a) v a� m � O0 Q wv 4 mN2 0.44) wwCCD I 3 M c d zt Z of z E a1 rn i E z c °o I N a m a m c t9 _0 o z v v r d Z w O w �` aci Z E v O) O O a O 0 '� M a a • E a� w . r- N o O C O , � I a r z m Z p Z m Z N � � z I O y m N .. m _ a 0 CL CQ � O 0 0 7 Aft (DI s W a C G a. O E N Q a C� > > Io tn tn v> > v` r ° v r - 0 aaa aaa z� m o . d vi vi LO a .. m CO CO is fA J U W Onj N l` Oni O~i O as } > } � 0 _ Q O N C') _ v Moo =_ p E ° a� m m rn m y c a ¢ min = v d < > m LO CD 0 O v E O D O , O co M C a p p O a c � w a0 N U')U') z C Q •� cd CL L a a+ I � a I • a '9 ° cai' °1a � � r`I�i y E A Ito) at OaL) NV I Parcel #: 040-1097-60-200 12/15/2005 09:42 AM PAGE 1 OF 2 Alt. Parcel M 25.28.19.386J 040-TOWN OF TROY Current Xi ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-JACKELEN BROTHERS AUTO JACKELEN BROTHERS AUTO 151 HWY 35N PO BOX 276 RIVER FALLS WI 54022-0276 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description SC 4893 SCH D OF RIVER FALLS �Sa -- SP 0100 CHIP VALLEY VOTECH n Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 25 T28N R19W PT S1/2 NE 1/4 COM NW Block/Condo Bldg: COR SEC 25, E 1086.5'S 52 DEG E 2175.8' N 89 DEG 387.4'S 29 DEG E 488.1'S 57 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) DEG W 562S 32 DEG E 400'-POB N 57 DEG 25-28N-19W E 217.8'S 32 E 200'S 57 DEG W 435.6'N 32 DEG W 100'N 57 DEG E 217.8'N 32 DEG more... / `��6 Notes: Parcel History: Z Date Doc# Vol/Page (Type 10/23/1997 567311 1272/64 (�(} WD 07/23/1997 -77W75' 2005 SUMMARY Bill M Fair Market Value: Assessed wi . 102786 366,600 Valuations: Last Changed: 11/06/2002 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 1.000 25,000 327,900 352,900 NO Totals for 2005: General Property 1.000 25,000 327,900 352,900 Woodland 0.000 0 0 Totals for 2004: General Property 1.000 25,000 327,900 352,900 Woodland 0.000 0 0 Lottery Credit:� re Claim Count: 0 Certification Date: Batch#: Specials: i User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT TOWNSHIP SEC. N, ST. CROIX CO , WISC0NSIN. xrfi . LOT LOT 'SIZE 9 y PLAN VIEW drrix►$, t � meet requirements of H62.20 t4 ti sw yItnl ' RYTHING WITHIN 100 FEET DP SYSTEM k i S 1 7 s a v + } u of Pi j f +t4 f 4 4 $ p R CONCRETE $ lEt. navex Depth DRY WELL nr n �tt1 length" area area— Unit of�tp P )XViD AREA AS BUILT Ipte, wm, this system by St. Croix County does not imply Si ate q xti4trative Codes. There are other areas that. it is not"possibl ` Z. ! + of construction. St. Croix County assumes no' liability' t ..H wevaar, if failure is noted the County will make every effort to failure. ` ,US 4HOULD .NOT BE DISPOSED THROUGH THIS SYSTEM. t yY INSPECTOR " � t, k. y Zip/PLUMBER, ON J xs LICENSE NUMBER OR f , QV.? � „t. Rr-PORT OF I1ISPECTION--174DIJIDUAL SM4AGE DISMUJ, SYSTEM Sanitary Permit • • r State Septic Z E- .,A 1E TOt•TNSHIR— Aa* • bt. Croix County MPTIC TA.,ii Size gallons. cumber of Compartments f . Distance From: Well ft. 12% or greater slope ft Building ` � ft. Wetlands f: Iiighwater ft. DISPOSAL SYSTE:1 Tile Field or Seepage Pit(s) Distance From: Well ft. 12% .or greater slope* — ft Building 0 ft. . Wetlands f;. FIELD Highwater . ft. Total length of lines t. Humber of lines Z Length of each line )—ft. Distance between lines ft. Width of the trench �� ft. Total absorption area �� � . sq. ft. Depth of rock below tile/—in. Depth of rock over tile in. Cover -Over.rock., I Depth of tile below grade in. SioPe of . trench i t per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS :lumber of pits Ou i ' i meter ft. Depth below inlet ft. Gravel aroun pi : eyes no. .Total absorption area sq. ft. Square feet of seepage trench tom area required ::guars feet of see ge pit a r quired Inspected 1iy_ �' jf/ Title':- . • Approved - '� , Date C �'� 1979. Rejected Date 197 State of Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES - --��.»,,,,,. DIVISION OF HEALTH MAIL ADON[SS: P. O. SOX 900 MADISON. WISCONSIN 08701 IN REPLY PLEASE REFER T0: SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS Pan Identification No. l P"1 Coll" 4sm f d %* S, 1 164 %�'. • Dear Sir: Re: ""00 # tSPM1 Me 04 see. 260 ink 149#0 Yam of V1 - St. Ovix ftoty This is to acknowledge receipt of your plans and specifications for the above- indicated project. When referring to this plan in the future, it will be absolutely necessary to utilize the plan identification number assigned to the project. The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section H 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the Department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates the plan review Fee required is $ Fee received is $ � �,-- ❑ Plan accepted for review. Fee is being returned because of ❑ Overpayment ❑ Underpayment. Providing one of the two catagories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. ❑ No fee has been remitted. Plan submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. 0 Additional information required. See attached Plb. 100. ❑ Affidavit sent. �] Plans being returned. See attached Plb. 100. Sincerely, A es A. Chief JAS:lds 1'lb 100a x/77 .. Department of Health & Social Services Division of Health Section of Plumbing and Fire Protection Systems 608-266-3815 Re: In reply refer to Plan ID The plans indicated above have been given a preliminary review and the following data is either missing or needs clarification. Please submit the additional information as indicated and checked below. Upon receipt of this additional data, plan review will be continued. I. Plan Submission ❑Additional information shall be submitted in triplicate unless specifically noted. Plans not clear, legible or permanent. All information submitted shall be signed, sealed or stamped in accord with Section H 62.25(2)(a) Wisconsin Administrative Code. ❑Affidavit enclosed. II. Alternate Sewage Disposal Systems (Mound Systems) PLB 108 (Application for use of an alternate system). ❑ County onsite required (1 copy). Cross section of mound. ❑Pipe lateral layout. ❑Plan view of alternate. III. Private Sewage Disposal Systems '-]Ground slope with 2' contours in entire area of soil absorption system extending 25' on all sides. El Elevation of permanent reference point (benchmark). <Location of area suitable for replacement system - provide soil test data. _] Plot plan showing lot size and all lateral distances from sewage disposal system or holding tank to bldgs, lot lines, well, watercourse, etc. Ll Construction detail of septic, holding or lift pump tank if site constructed or tank manufacturer if precast. )Construction detail and cross-section of soil absorption system. Soil boring and percolation test on EH 115 completed by certified soil tester (1 copy). IJ Complete data relative to anticipated use of bldg. ❑3 copies of PLB 60 enclosed. L:]Deed restriction required (1 copy). IV. Holding Tanks ❑Profile of holding tank. LJ Holding tank agreement signed by owner and local unit of government (sample enclosed). LJReason for installing holding tank soil test or statement from county (1 copy). V. Lift Pumps L]Calculations for total lift pump discharge, head and gallons pumped per cycle. Size, length & depth of force main. LiDetail & model of pump or automatic siphons including size, pump curves, drawdown and average flow rate GPM. ❑Cross section of lift pump tank showing pumps) or siphon(s). VI. Water Supply, Distribution & Service ❑Sizing calculations. ❑On/off pressure of pump if private water supply or static pressure at source if public supply. Gallons per minute of pump.and size of pressure tank. ❑Size of pipe, length of run and materials used. VII. Systems In Fill Fill must be placed prior to plan submission) ❑Total area filled (fill to extend 20' beyond edge of trench before side slope begin). 0 Depth and type of fill. ❑Copy of onsite report by county or district plumbing supervisor. ❑Length of time fill has been in place. -over- SAMPLE DRAWING - NOT TO BE SUBMITTED FOR PLAN SUBMITTAL- - B£�.ICH MARK ` 1 \I SEPTIC I LOT LIME / 11 TAM K 1 � I / WELL 1 ' 9 2' 98. i � � ji Iljl III I 1 I � i \/ DETAIL 'A•A' /ZH" VEti1TS'—LOT LIQE ELIT AR,, —PLOT PLAKJ — JOHN DOE M.P.*OOOO PRIVATE SEWAGE DISPOSAL SYSTEM �oR.R poe SCALE — 1"=40'-O'* 5'-O"MAX. (o' - O"MIDI. MARSH NAY OR UMTREATED D[si P . APER F PIP 4 PER E EARTH i GRAVEL — DETAIL "A-A" NOT TO SCALE Mop , +vy �^^''., b i � ^r,, ... T �j�!(� Y,tiF,,. ! �V,.:- . des. ':) ✓': �%1 "" .a �Yr - : 4..�w ii _ R��' y ; Kos ",- ;t53�' 3 '• r lr� ,�-w r .. r y ?y. � s 4d t �biX +�+Sr';{. '�:•+ f+a tY '"p.�^a• .,,, y&�•�i•.. r }"a 1: P'%::. 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" ',,��. �r � , r=° t `t t: % d. � �� �,�:. r �r,� y��* �., .�... 7 ecf�" ��y' M1�.. z✓ ,q,�-" ��4� �' �'���F „, _� � z� Tit�'� f �1H,f�," � .'v.' `mss t?•'fs }�`f�'��'� �T3" �irG X t t � .� � Zr e � �� �� �� y � � �t H� F l��'. !ti S. F! 1+:A � y� '"�,�5iL �♦ tea:. r ��w r:.� ,";, ;�%{ -�, s} u ��': E �. i • S —1 W ! _ I! i '•r�i 1 t i I � i I � � 1 CD O W D: a LP i � I mac/ (,tN a � � i i I ' 'a f; 1 ja • r 1.> \I 3 � `¢ 0 r ,C :c r. N �. v-, � Cwt � � -�l•F � -' � `� �C 1 tl o CD a (D Q c N CD + ' •",� i n Q { ;n Sit O (G 0 i 0 0, �+ ' � i rib. 8 ou 70 PROJECT DETAIL DATA SHEET NE OF BUSINESS S LOCATION street or highway city or ownship county LEGAL DESCRIPTION ------- OWNER S (L I 0 - Mailing address S30 n ZIP Z ARCHITECT OR ENGINEER Address !' ZIP PLUMBER Y Address Ai--I ZIP���, 1 . Check appropriate building usage(s) and fill in the information requested opposite each usage listed: Existing building New building Addition If addit on to existing building attach detailed memo for each. ( ) Drive in restaurant, . . . . . . . . . Car spaces O Restaurant Seating capacity (10 sT ./person) waste Yes No person) ( ) Dining hall Per meal served Toilet ( ) Motel ( ) Hotel ( ) Cottages . . Number of un tlrs: 2 persons/unit 4 persons/unit TOTAL NUMBER OF UNITS ( ) Churches . . . . . . . . . . . . . . . . . Number of persons Kitchen Yes No I� ( ) Bar or cocktail lounge . . . . . . Seating capacity (1 0 sq. ft./person) ( ) Nursing or rest home . . . . . . . . Number of beds ( ) Mobile home park . . . . . . . . . . . . Number of units - dependent (camper trailer) - no;T0S'1q.dent (mobile home) Retail store . . . . . . . . . . . . . . . . Number of employees f erson - ustomers t./p ) 30 �� Number of c �� Service station . . . . . . . . . . . . . Number of cars served (daily) O School . . . . . . . . . . . . . . . . . . . . . . Number of classrooms Meals served Yes No Showers provided Yes No ( ) Factory or office building . . Number of persons (total all shi is ( ) Apartments . . . . . . . . . . . . . . . . . . Number of bedrooms ( ) Other . . . . . . . . . . . . . . . . . . . . . . . Specify _-- _--- 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes No 1 I hwasher Yes No Automatic clothes washer Yes No Automatic potato peeler Yes Other . . . (Specify) _ �__� No 3. Fill in the appropriate information for the following as indicated: Septic tank capacity planned -7 rO 4 y5 f 60 R k-1 .�V l R-t DO w. S f Cr> Percolation test results - ATTACH PERCOLATION TEST AND SOIL BORINGS EPORT SHEET COMPLETE OTHER SIDE I ,. r ::n? R _ F; i I a �. I Seepage trench bottom area planned width Y linear feet depth _ Seepage be& area planned width _ Al depth . 1 i✓near feet Seepage pit planned outside diameter _ depth below inlet depth l 4. See approved plan for specifications and details. Signature of person comp 4 form: STATE DIVISION OF HEALTH, PLUMBING SECTION P. 0. Box 309, Madison, Wisconsin 53701 Approved: Address: Date: ZIP a THIS APPROVAL IS BASED ON STATE PLUMBING [� CODE REQUIREMENTS AND DOES NOT EXEMPT THE Date: J ✓. Z� INSTALLATION REQUIREMENTS TOWNSHIP SHALL BE VOID IF REVISED WITHOUT THE WRITTEN APPROVAL OF THE DIVISION OF HEALTH. DEPARTMENTAL USE ONLY j i i i k . sFG ri f' 1 n, F r� � s T7�fa a _5 A `fig. .3' WAI x k Ate. ommm .. ,. ` 4z 1 ' - aF s4- 34 i i B Of Via ni r a z , -il- 1 y ; a ' h � , j Y L T P $ , r 3 t L r 4 4 �' ` e Y.+.,o ♦ -?q A--i Vii. "e' ° y F � At ' State and County State Permit PLB67 Permit Application County Per -� • for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED 'J 49, Q �/� Date Approval Received from State if Required State Plan I.D. # 1 A. „ OWNER OF ROPERTY Mailing Address: 97 ATION: '/A& '%, Section�67, T N, R E (o Lot# City_ Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex o. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder_YESNO # of Bathrooms— Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement_ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft. New Addition Replacement *Fill System Seepage Trench: No. Lin. Feet�.1.Width `..Depth Tile Depth No. of Trenches Seepage Bed: Length Width �Depth Tile Depth No. of Lines ' Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certifi Soil Tester, /. NAME Gil��J .S.T. # J�Jr-'�°� /and other information obtained from owner/builder). g O 9 Plumber's Signa - MP/MPRSW# � "9� / Phone *7c74)— / Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). s r 1 i E r i i - - s r > i F_ r i i 1 t t E ' i t Ei a �g z , E , E t Do Not Write in Space Below - FOR DEPARTMENT USE ONLY p Date of Application — Fees aid: State�� Count �� Date D PP p Per pit 1c�—JJO-+weted (date) Issuing Agent Name Valid# Date Recd owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 ' -r (canary copy) Revised Date 6/1/76